The New York Times
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August 19, 2008
Personal Health
In Cancer Therapy, There Is a Time to Treat and a Time to Let Go
By JANE E. BRODY
Thirty years ago Forbes Hill of Brooklyn learned he had prostate cancer. At age 50, with a young wife and a fear of the common side effects of treatment — incontinence and impotence — he chose what oncologists call “watchful waiting.” For 12 years, Mr. Hill was fine. Then in 1990 his PSA count, a measure of cancer activity, began to rise, and he had radiation therapy. That dropped the count to near zero. In 2000, with the count up again, he chose hormone therapy, which worked for a while.
Three years ago, with his PSA level going through the roof, he learned that the cancer had spread to his bones and liver. It was time for chemotherapy, which Mr. Hill said he knew could not cure him but might slow the cancer’s progress and prolong his life.
His oncologist was candid but not very specific. His doctor told him that with advanced metastatic hormone-resistant cancer like his, 90 percent of patients die within five years no matter what the doctors do, and about 10 percent survive six or more years.
“I took that kind of hard,” said Mr. Hill, an associate professor of media studies at Queens College. “I always thought I would live to 90, but I guess now I won’t.”
He has just started radiation to the brain, perhaps with infusions of an experimental drug afterward. “I’ll try chemo for six months, but if it gets too uncomfortable and inconvenient... ,” he said, trailing off. “Having lived 80 years, I’ve done a lot. I don’t have reason to think I’ve been badly treated by life.”
Mr. Hill seems ready for a time when treating his cancer is no longer the right approach, replaced instead by a focus on preparing for the end of his life.
But doctors who have studied patients like Mr. Hill say that often they do not know when to say enough is enough. In a desperate effort to live a month, a week, even a day longer, they choose to continue costly, toxic treatments and deny themselves and their families the comfort care that hospice can provide.
Tough Decisions
Specialists in ovarian cancer from University Hospitals Case Medical Center in Cleveland described a study of 113 patients with ovarian cancer in the journal Cancer in March.
“Patients with a shorter survival time,” they found, “had a trend toward increased chemotherapy during their last three months of life and had increased overall aggressiveness of care [but] did not have improvement in survival.”
The team concluded, “Our findings suggest that in the presence of rapidly progressive disease, aggressive care measures like new chemotherapy regimens within the last month of life and the administration of chemotherapy within the last two weeks of life are not associated with a survival benefit.”
With aggressive therapy, the majority of the women in the study who died did so without the benefit of hospice.
Dr. Thomas J. Smith, an oncologist and palliative care specialist at the Massey Cancer Center of Virginia Commonwealth University, said in an interview that patients needed to understand the tradeoffs of treatment.
“Palliative chemotherapy, which is what most oncologists do, is meant to shrink cancer and improve the quality and quantity of life for as long as possible without making patients too sick in the bargain,” he said.
The Cleveland team pointed out that the treatment goal can, and should, change. “There is a difference between palliative chemotherapy administered early in the trajectory of disease and near the end of life,” the researchers wrote. “The goal of end-of-life care should be to avoid interventions, such as cytotoxic chemotherapy, that are likely to decrease the quality of life while failing to increase survival.”
In fact, those who choose hospice over aggressive treatment often live longer and with less discomfort because the ill effects of chemotherapy can hasten death, Dr. Smith wrote in a review of the role of chemotherapy at the end of life, published in June in The Journal of the American Medical Association.
Some patients are just unwilling to acknowledge that nothing can save them, and want toxic treatment even if it means only one more day of life.
And sometimes patients are reluctant to relinquish treatment because they are terribly afraid of dying, of being alone cut off from care, Dr. Smith said in the interview. Patients may fear, with some justification, that if treatment stops the doctor will abandon them.
It is not only patients and their families who may insist on pursuing active treatment to the bitter end. Sometimes, doctors subtly or overtly encourage it. Oncologists may be reluctant to acknowledge that they can no longer sustain a patient. They may fear destroying a patient’s hope. Or they may be covertly influenced by the fact that their income comes from treatment, not from long discussions with patients and families about why palliative therapy should yield to supportive care.
Dr. Smith says that cancer treatments “have a huge price tag of up to $100,000 a patient per year,” which can impoverish even insured patients when there is a 20 percent co-pay.
He urges doctors to talk about hospice early, while treatment options are still available, and to assure patients they will not be abandoned in hospice.
Switching to Comfort Care
While there is no official definition of futile care, Dr. Smith suggests that it represents care that is “very unlikely to help and likely to harm.”
The National Comprehensive Cancer Network has established some guidelines about when to switch to comfort care. They vary according to the type of cancer and nature of available treatments, but in general they include when a patient has already been through three lines of chemotherapy or when their performance status — how well they can function in daily life — is poor.
Dr. Smith said most chemotherapy regimens had been tested only in patients who are relatively well, independently mobile and able to perform most of the tasks of daily life.
For those who are confined to a bed or a chair for half or more of the day, “it is time to think long and hard about continuing treatment,” he said. “It’s time to have an extensive discussion with patients about their goals and the risks and benefits of chemotherapy.”
He suggested that doctors “put everything in writing — here’s what you have, what we can do for it, what will happen with treatment and without it — so that everyone is on the same page,” eliminating the risk that wishful thinking colors what patients hear.
When faced with a patient who says, “I’ll do anything to live two minutes longer,” Dr. Smith said the doctor should ask: “What is your understanding of your illness? What would you like to do with the time remaining?”
For most people, he added, the time left would be far better spent putting their affairs in order, preparing their funeral or memorial service, repairing damaged relationships, leaving lasting legacies and saying their goodbyes.
Tuesday, August 19, 2008
Friday, August 15, 2008
Elder Abuse
Forensic Issues for Nurses -- Elder Abuse
A Betrayal of Trust
Behind closed doors, in the places they call home, many frail, older individuals are harmed by someone they trust. It might be the person who helps them get up in the morning, cooks their meals, or changes their bed linens when they are incontinent. Sadly, this person is not always a paid caregiver who can be dismissed. Often the abuser is a family member, even the elderly person's own spouse or adult child.[1] The nature of the relationship between the elder and his or her abuser is central to understanding mistreatment of the elderly,[2] and stranger violence is excluded from the definition of elder abuse.[3] Conceptually, the core of elder mistreatment is found where age, vulnerability, and a trust relationship intersect.[2]
The tragedy of elder abuse is a growing social problem that crosses all ethnic, racial, economic, and religious lines. That elder abuse has its own specialty (forensic gerontology) and role (geriatric forensic nurse examiner) within the forensic nursing community speaks to the magnitude of this problem.[4] There are many forms of elder abuse -- physical, emotional or psychological, sexual, neglect, abandonment, financial or material exploitation, and self-neglect -- and multiple forms can coexist (Table 1).[5] This article will focus on physical and sexual abuse.
An Epidemic of Mistreatment
Just how many people aged 65 years or older have been abused by someone on whom they depend for care and protection is unknown.[2] Both underrecognized and underreported, elder abuse is a story that can't be told with numbers.[6] We do know that reported incidents of elder abuse are increasing, but formal reports represent only the tip of the iceberg.[7] The National Center on Elder Abuse estimated, in 1996, that only 21% of instances of abuse of a person aged 60 years or older were reported to adult protective service (APS) agencies.[8] A recent systematic review of elder abuse literature concluded that 1 in 4 elders is at risk of abuse,[9] and the Senate Special Committee on Aging believes that as many as 5 million elderly Americans might be mistreated every year.[10]
Healthcare professionals must be vigilant for elder abuse in the clinical setting because an ordeal such as abuse can have far-reaching consequences. The trauma of abuse is magnified in the elderly; it often leads to hospitalization and can significantly shorten the elder person's life.[11] With few strong social support systems and dwindling physical, psychological, and economic reserves, the elderly don't bounce back from the cruelty of abuse.[12] A single incident of maltreatment can trigger a downward spiral leading to loss of independence, serious complicating illness, and even death.[12]
Shame, self-blame, denial, fear of reprisal, unwillingness to accuse family members, or a desire for privacy can all make the older victim reluctant to report abuse to authorities or healthcare providers.[13] Anne Burgess, RN, DNSc, Professor of Psychiatric Mental Health Nursing at Boston College and elder abuse researcher, notes that elders who live at home are fearful that if the abuse is reported, they might be taken out of their homes. "Abuse robs them of their independence," explains Burgess. Cultural characteristics can make some elderly individuals less willing to discuss potential abuse. Some elderly people may not even realize that what they are experiencing is abuse or, if they do, may simply not know how or to whom to report it.[2] For all of these reasons, an astonishing 72% of elders presenting to the emergency department following an incident of abuse do not complain of abuse.[13]
The Circumstances of Abuse
The characteristics of abused elders, both personal and situational, are important in both identification and intervention for elder victims of abuse. Advanced age, absence of significant others, poor health, depression, and cognitive, physical, or functional impairment are the attributes most often associated with victimization in the elderly.[14] Victims are more likely to be female, to suffer from chronic illness, and to live with the caregiver who mistreats them.[15]
Improved understanding of those who abuse and why they abuse is necessary for prevention and early intervention efforts.[16] Perpetrators are more likely to be male, to be emotionally or financially dependent on the elderly person, and to suffer from mental illness, depression, or substance abuse. A poor relationship between the abuser and the abused is often present.[17] Sometimes the abuse is long-term -- essentially spousal abuse that has progressed into old age.
Why does someone intentionally harm an elderly person? Several theories have been proposed. The phenomenon of transgenerational violence posits that children who were abused are more likely to mistreat the parents who abused them.[18] Caregiver stress, from the sometimes overwhelming burden of caring for the elderly, may also be a factor in maltreatment. In generational inversion, the role of parent and child are reversed, and the adult offspring finds it difficult to assume the role of caregiver.[18] When hospitals discharge elderly individuals who require ongoing care into the hands of relatives who don't have the knowledge or ability to provide the necessary care, this could be an abusive situation in the making.[19]
High-risk situations include drug or alcohol addiction in the family, isolation of the elderly person, physical and functional disability, a history of untreated mental illness, a history of family violence, unusual family stress, or excessive dependence of the elderly person on his or her caretaker.[18]
Assessment and Care of the Elderly Patient
Unless you work exclusively in pediatrics, neonatal care, or maternity nursing, geriatrics is part of your practice. Furthermore, this segment of your practice is growing as baby boomers reach retirement age and medical advances extend life expectancy. Few of us are geriatric forensic specialists, and most of us were not taught how to identify and properly document the effects of elder abuse.[20] Still, we must be ready to address the healthcare issues of the aging population, including the needs of the geriatric forensic patient. Hospitals should have a policy for assessing elder patients who might have been abused and for following state legal requirements for reporting and protecting patients from further harm.
Collecting and documenting evidence of abuse is as important in the elderly as it is in children or other patients who have experienced interpersonal violence. Patients with cognitive impairment may be unable to speak for themselves, and, with no witnesses, the full burden of proving abuse rests on the forensic evidence.
Let the Injuries Speak
Dan Sheridan, PhD, RN, FNE-A, SANE-A, FAAN, a forensic nurse examiner and Associate Professor at the Johns Hopkins University School of Nursing, is a strong believer in listening to what injuries are telling him. What appears to be the mechanism of injury? Could assault mechanisms have been involved? Where are the injuries located? Are they on the head, face, and neck, where most injuries from interpersonal violence are found? Are they on the upper extremities, suggesting the possibility of defensive wounds?[21]
When a patient's injuries reveal that they might have been caused by abuse, the nurse must proceed with institutional guidelines for suspected interpersonal violence. As soon as the patient is medically stable, evaluate the wounds for possible trace evidence that might be important in legal proceedings at a later time. Before you wash this trace evidence away or drop it on the floor, preserve and document it.
Mechanism of injury is the exchange of physical forces that results in injury, such as that from a fist, bottle, or bullet.[21] The nurse should look for patterned injuries that display the shape of the object that caused the injury (like a cane or a baseball bat) as these are more likely to be man-made than accidental.[22] Looking at injuries and trace evidence in this way assists in determining if the injuries are consistent, or inconsistent, with how the patient or those accompanying the patient say that the injuries occurred.
Questioning Patients About Abuse
In any setting where elderly patients are encountered, nurses must maintain a high level of suspicion for possible abuse. Screening tools to aid in the identification of elder abuse are available. However, Sheridan has a simple approach for questioning the elderly patient, one that he finds extremely effective in eliciting reports of abuse while simultaneously emotionally supporting the patient.
First, explains Sheridan, it is critical to question the elderly patient alone. Someone among the patient's caregivers or family members could be the abuser, and the patient will not speak freely in their presence. If you ask the patient about abuse in front of the abuser, you might as well not ask at all.
Your first statements are intended to make the patient feel at ease, to convey that there is nothing unusual about the questions you are asking, such as, "Violence is pretty widespread these days -- so widespread that it sometimes spills over into the home. I'm going to ask you a few questions that I ask all my patients."
Next, Sheridan suggests asking: "Where you are living now, are you afraid of anyone?" and then remain quiet to allow the patient to respond. This first question is designed to elicit the emotional aspects of abuse before proceeding to the physical aspects. Sheridan believes that if he demonstrates to the patient that he understands that abuse hurts, emotionally, the patient is more likely to tell him about the physical abuse. Emotional abuse takes longer to heal than physical abuse.
If the answer to the question is yes, then follow up with these 3 statements/questions:
* Thank you for sharing.
* Can you give me an example of how you were afraid?
* When was the last time you were afraid?
The next question is, "Have you been hit, or slapped, or otherwise physically hurt by anyone?" Again, if the patient indicates, "yes" ask the same follow-up questions, along with conveying your sorrow that this happened to the patient. Finally, Sheridan suggests asking the patient if "anyone has forced you to do something sexually that you did not want to do?" After finding out the last time this happened, offer the patient a sexual assault examination.
Throughout questioning, the nurse must remain aware that a patient's reluctance to speak candidly might be related to fear of retribution or institutionalization. It is important to layer questions with emotional support and acknowledgment of the patient's fears about personal safety and other concerns and reassure the patient appropriately.
Forensic Red Flags
When the signs are subtle and the victim is silent about it, elder abuse can easily pass unnoticed.[13] In home care, public health, long-term care, primary care, acute care, emergency care, and outpatient service settings such as dialysis, nurses can uncover elder abuse. Abuse can occur in the home as well as in senior residences and skilled care facilities. Evidence-based markers suggesting abuse or neglect should be part of systematic assessments of elderly patients in all settings of care, regardless of where the patient came from (Table 2).
Repeated visits to the emergency department for complaints of injuries or falls can be an indicator of mistreatment.[19] Verbal reports of harm made by the elderly patient should not be dismissed, even if cognitive impairment is suspected.[2] Allegations should be investigated by an appropriate professional or by law enforcement.
Psychological abuse may be suggested by signs of helplessness, confusion, or disorientation, emotional upset or agitation, unexplained fear, sudden changes in behavior or unusual behaviors (eg, rocking), withdrawal and not responding, or denial and implausible explanations.[19]
Forensic Examination
When preparing to conduct a forensic examination of the elderly victim of abuse, the nurse first obtains consent from the elderly patient or appropriate family member. The exam follows the institution's protocol for conducting an evidentiary exam, preserving evidence, and taking photographs.[23] Some emergency departments find it helpful to maintain a forensics cart, analogous to a crash cart, that contains evidence collection materials. Healthcare professionals who are providing care or collecting evidence must be sensitive to the fact that the elderly individual who was abused by another healthcare worker might fear healthcare professionals.
Physical Abuse of the Elderly
One of the reasons that it is so easy to overlook elder abuse is that there are no hallmarks of abuse in the elderly the way there are in children.[2] Old age often brings medical conditions and physiological attributes that may mimic or mask the markers of elder abuse and neglect.[24] While it can be difficult to ascertain that the elder's signs and symptoms are related to abuse, nurses must remember that they don't have to prove whether or not abuse occurred but only take the appropriate action for suspected abuse.[19]
A common mechanism of abuse in the elderly is the blunt force injury. Blunt force injuries are most often inflicted by punching or slapping with the hands. The major types of blunt force injury seen in interpersonal violence are contusions, fractures, abrasions, lacerations, and internal injuries. Some of these injuries can be accompanied by welts, which are raised, reddened areas caused by striking the individual.
Contusions
Thinner skin, fragile blood vessels, and little subcutaneous fat make the older individual more prone to bruising.[23] Medications, nutritional status, and concurrent medical conditions may also play a role in the occurrence and resolution of bruising in the elderly. Bruises occur more frequently and resolve more slowly in older vs younger persons and can last for months instead of the usual 1 to 2 weeks.
Bruises (also known as contusions) are caused by the rupture of tiny blood vessels under the skin, without breaking the skin.[2] The skin of the eyelids, neck, and scrotum of elders bruises very easily, as do their vulnerable arms and legs.[25] Bruises can also result from squeezing the elderly person. Some bruises retain the shape of knuckles, fists, or fingers used to inflict injury. Parallel bruises, with a lighter, nonbruised area between them, are called tramline bruises, or central clearing, an injury caused by striking the person with a rod-like instrument or stick. Upon impact, the traumatized blood cells in the center are pushed to the sides, resulting in an injury with darker sides and a central area that is lighter in color. Injury from forcing the legs apart during sexual assault might appear as fingertip bruising.
The elderly do fall, and when they fall, they bruise. Clinical differentiation between accidental and inflicted bruises in the geriatric population is difficult. The nurse should examine the elderly patient's entire body for and carefully describe bruises, regardless of possible cause. Objective facts regarding location, size, shape, and color of the bruise, along with the patient's statements about the source of the bruise, should be documented.[24] No attempt should be made to estimate the age of the bruise based on its color[24]; however, if the patient has multiple bruises that appear to be at different stages of resolution, this should be documented.[22]
Accidental bruising occurs in a predictable pattern in older adults. In a study funded by the US Department of Justice, involving 101 elderly individuals, Mosqueda and colleagues[26] found that 90% of accidental bruises occurred on the extremities, and 76% of those were on the dorsal surface of the arm. No accidental bruises occurred on the neck, ears, genitals, buttocks, or soles of the feet. Only 12 of 108 bruises were found on the trunk, all occurring in patients with hypertension, the only medical condition found to correlate with bruising patterns. Individuals on medications known to affect blood clotting were more likely to have multiple bruises, as were individuals with physical disabilities. Although color and appearance of bruises changed over time, the progression was less predictable than previously believed.[26] The ability to recall how the bruise occurred also varied. Subjects were more likely to recall the cause of bruising found on the trunk vs those found on the extremities.
Of note, Sheridan reminds us that nurses sometimes use the word "ecchymosis" erroneously in place of "bruising." Ecchymosis is not a synonym for bruise or contusion. Ecchymosis is extravasation of blood under the skin that can be caused spontaneously by medical conditions, such as thrombocytopenia. Elderly patients frequently have areas of ecchymosis that are not trauma-related. However, the word ecchymosis does have a limited use in the assault-related forensic vernacular. Extravasated blood from a vessel broken by trauma can track through fascial planes, resulting in a discoloration forming at a site remote from the original injury, a gravitational process known as ecchymotic spread. This is how a blow to the scalp can result in a black eye. If, however, the patient was actually struck in the eye, the discoloration in that area is a bruise. The blood from this bruise to the eye area can subsequently gravitate further downward.
Fractures
Low bone density and osteoporosis greatly increase the risk of fractures in the elderly, especially in women. Age, immobility, steroid therapy, cancer, poor nutrition, alcoholism, and hormone deficiencies can all predispose the older individual's bones to fracture.[22] Fractures range from a frank severing of the bone to splintering and compression of the bone.[25] The distal wrist and the hip are the most frequent sites of bone fracture in the elderly. The brittle thoracic rib cage of the elderly individual can lead to rib fractures when force is applied to the chest during an assault.[24]
There are no particular fracture patterns known to be associated with elder abuse.[27] An orthopedic surgeon is the ideal professional to evaluate whether the musculoskeletal injuries correlate with the reported cause of the injuries.[27] Dentists and oral surgeons often see physically abused patients with fractured, subluxed, or avulsed teeth or fractures of the zygomatic arch (the bony structures around the eyes) or the mandible and maxilla (jaw bones).[28]
Abrasions, Lacerations, and Cuts
The elderly victim should be assessed thoroughly for abrasions, lacerations, and cuts, and these injuries should be accurately described using the correct terminology. "Nurses tend to call every wound that is open and bleeding a laceration," explains Sheridan. "But they aren't all the same, and nurses need to learn the differences."
An abrasion is a scraping injury that occurs if the victim is pulled or dragged across a surface that abrades the skin.[24] Abrasions are superficial injuries involving the outer layer of skin. Abrasions are caused by movement of the skin over a rough surface.
Lacerations, sometimes referred to as gashes, are characterized by full-thickness splitting or tearing of the skin, occurring when blunt force is applied. Lacerations often occur over bony prominences and often result in additional trauma to underlying structures.[21] Cuts are very different from lacerations; they are incisions made with sharp objects. Cuts have smooth, clean edges in contrast to the ragged edges of lacerations, evidence that can be seen with a magnifying glass.
Head Injuries
Trauma to the head is more likely to result in a subdural hematoma and carries a greater risk of morbidity and mortality in an elderly individual compared with a younger person.[24] The patient should be evaluated for head injury whether or not there are symptoms.[24] If there is headache, change in mental status, or disturbance in gait, the possibility of head injury must be explored,[24] recognizing that it can be difficult for the healthcare professional, without the observations of those close to the elderly patient, to separate pre-existing neurologic deficiencies from symptoms of a head injury. It is important to assess the scalp for injuries as well. Patchy hair loss suggests violent hair-pulling.[4]
Sexual Assault of the Elderly
Frail elders are vulnerable not only to physical abuse but also to sexual predation.[12] Sexual victimization is most underreported in those over the age of 60 years.[12] As in other forms of abuse and neglect, shame and fear of retaliation prevent many elderly victims from reporting sexual crimes. Furthermore, the stereotype that older adults are not sexual or sexually attractive is a barrier to the detection of sexual abuse in this population.[29] Educating healthcare professionals, including caregivers in long-term care settings, about sexual abuse in the elderly may improve detection.[29]
In a retrospective analysis of the characteristics of 125 elderly sexual assault victims, aged 60 to 98 years, Burgess and colleagues[12] found that one half suffered from a physical disability, 46% from a mental disability, and 33% were diagnosed with dementia. Physical injury was found in 75% of the victims, including a head injury in 38%, abdominal injury in 15%, arm injuries in 30%, vaginal trauma in 45%, and anal trauma in 17%.
What happens after the assault can profoundly affect the subsequent course of justice. Only 37% of the elderly victims described above received forensic examinations. Destruction of forensic evidence (if patient voided, defecated, showered, changed clothes, or brushed her teeth) reduces the likelihood of the offender being charged and found guilty.[12]
In many cases, no anal or pharyngeal specimens were obtained, and vaginal tests were done in only a quarter of the victims. Rape kits were not consistently used and processed, and testing for sexually transmitted diseases was rare. Only 23% of victims were assessed for posttraumatic stress disorder (PTSD). Almost half of these women lived alone at the time of the assault, 38% lived in a nursing home, and 6% in assisted living. Perpetrators of nursing home sexual assaults are rarely prosecuted and convicted of the crime.[12]
Conducting a rape exam on an elderly woman can be difficult if she cannot be placed in the pelvic examination position or has contractures, arthritis, or other conditions prohibiting this position.[24] The patient may be physically resistant to the rape examination and evidence collection.[29] A high-intensity light and small narrow speculum should be used to inspect and photograph any injuries to the exterior genitalia and, if possible, the posterior aspect of the entrance to the vagina and the perineum.[24] Lacerations, abrasions, and bruises may be found in these areas. It is recommended that the exam be conducted by a sexual assault nurse examiner or forensic nurse examiner.
Elderly sexual assault victims are at high risk for posttrauma symptoms such as numbness ("shock"), physiologic upset, startle reflex, and anger.[30] Posttraumatic sequelae are often overlooked by healthcare professionals or ruled out as being normal variants of the aging
process,[30] yet these are serious issues that affect the elder's quality of life. Elderly patients who have been sexually assaulted should have psychotherapeutic intervention in the aftermath of the assault.
Documentation
Data entered into the medical record can be used as evidence if elder abuse is prosecuted or there is a civil lawsuit. Documentation may also be used in guardianship hearings.[31] The nurse should document findings of physical examination, forensic evidence collection, and any statements made by the patient or those accompanying the patient as objectively and accurately as possible. The chain of custody must be maintained on any physical evidence collected for forensic
purposes.[31]
Nonforensic nurses often make documentation errors that can even result in their documentation and testimony being excluded from legal proceedings at a later time. One of these errors, according to Daniel Sheridan, is using the word victim when charting. "The word victim should never appear in the medical record," explains Sheridan. "We care for patients, not victims. Using the word victim suggests that the nurse has already decided that the patient was abused, and he or she is biased in favor of abuse."
Another legal term that should not appear in nurses' documentation is "alleged." "If it would be inappropriate to chart alleged chest pain, it is just as inappropriate to chart alleged elder abuse," Sheridan said, adding, "instead of charting alleged, replace it with reported or suspected." To maintain objectivity, the nurse should document the statements made by patients, family members, or caregivers. It is wrong, however, to sanitize or medicalize the patient's words. Sheridan explains that nurses should try to write down patient statements verbatim, in quotes, without changing the patient's words, including slang terms for body parts, to those that a medical professional might use.
Next Steps
Although forensic evidence collection is important, nurses must also initiate the processes of safety, services, and support for elderly victims.[5] Social services, counseling, and legal assistance should be initiated.[4]
Safety for Abused Elders
Elderly victims of abuse are usually incapable of protecting themselves. It is imperative for healthcare professionals who suspect abuse to intervene and ensure the safety of the elderly patient. It is obviously a difficult situation when the abuser is the family member, caregiver, or friend who accompanied the patient to the healthcare facility. The nurse must make the best assessment possible of the potential danger in the patient's living situation.
Plans must be rapidly formulated if the injured elder is going to be released from the emergency department, acute care, or urgent care facility, to prevent sending the victim back to an unsafe environment.[32] Following state and institutional elder abuse reporting guidelines is the first
step.[32] Nurses are often reluctant to fulfill their responsibility to report suspected elder abuse, preferring to leave it to the social worker or some other individual to do the reporting. However, as Daniel Sheridan points out, the nurse is the one closest to the information, who has assessed the patient and talked to the patient and family, and should be the one making the report.
States have made it very easy to report suspected abuse of older adults, and most require healthcare professionals to do so. For example, Virginia law designates, among others, anyone who holds a license granted by a health regulatory board, such as the Board of Nursing, as a mandated reporter of elder abuse. A 24-hour toll-free elder abuse hotline is available for immediate reporting. Failure to report suspected abuse within 24 hours in Virginia can result in civil fines.[33] Texas law requires any person who believes that an adult over the age of 65 years or with disabilities is being abused to report the circumstances to the Department of Family and Protective Services, and failure to do so is a Class B misdemeanor. Suspected abuse can be reported confidentially via telephone hotline or the state's secure abuse Web site.[34] Some state attorney general offices and district attorney offices have established special elder abuse investigation and prosecution units.
A complete list of states' links to government agencies, state laws, state-specific data and statistics, and resources for elder abuse is available at the National Center on Elder Abuse (NCEA) Web site.
Services for Abused Elders
APS agencies aim to ensure the safety of the elderly person at risk of being mistreated, and who is unable to protect him or herself.[1] Most jurisdictions specify that reports be made directly to APS, but others require the report to be submitted first to law enforcement.[2] Reports of abuse, exploitation, or neglect are investigated by APS agencies to determine the need for casework services such as monitoring and evaluation. These agencies arrange for medical care, social services, economic or legal aid (including restraining orders), safe housing or shelters, and other protective and supportive services. Adult protection agencies also liaise with law enforcement as indicated. APS caseworkers are often the first responders to reports of elderly abuse, neglect, or exploitation.[1]
APS can offer services to protect the elderly victim, but these services are voluntary; the elderly individual can choose to accept or decline them. APS can arrange for emergency housing, cleaning services and home repairs, medical services and medications, referral to other healthcare providers, and assistance with applications for healthcare benefits; addressing personal needs for food and caretaker services. APS can also coordinate care and support on a short-term basis, provide a client advocate and implement legal interventions, such as restraint orders, guardianship, involuntary mental health commitments, and emergency removals.
Attention to elder abuse lags significantly behind that for child or spousal abuse.[4] Oddly, society seems more tolerant of abuse in the elderly than in children. Nurses rarely hesitate to contact child protective services in cases of suspected child abuse. We might, however, neglect to pick up the phone on behalf of the elderly patient with injuries suggesting abuse. Whether this reflects ageism, lack of time, lack of clarity as to what constitutes abuse, ignorance about reporting protocols, or respecting the elderly patient's wishes isn't yet known.[4]
Support for Abused Elders
Follow-up care is necessary to ensure the well-being of the victim of abuse.[32] APS is one source of ongoing support services, but other community-based services such as adult day-care, respite care, and caregiver support services should also be used. A home care or visiting nurse is vital for elderly victims released to the environment where mistreatment occurred. Sometimes an older adult will decline services of any kind and insist on returning to the setting of mistreatment. Unless there is true cognitive impairment, healthcare professionals cannot force the elderly person to go to a shelter or move to a protected living situation. This can be an ethical dilemma for nurses taking care of the elderly patient. Written materials, with 24-hour emergency numbers, should accompany the elderly individual who declines services.
A geropsychiatric consultation is important for elderly victims of assault. In those who are cognitively impaired or have documented dementia, the geropsychiatric nurse can conduct a detailed assessment and determine if impairments exist that preclude self-determination.[32] The geropsychiatric nurse can evaluate the elderly patient for PTSD or rape trauma related to sexual assault. Posttraumatic symptoms should not be overlooked or written off as medical or psychological signs of aging.[30]
Prevention of Elder Abuse
Nurses and other caregivers must be trained to identify the signs of elder abuse, even when the patient does not volunteer the information. If healthcare personnel are skeptical about the reality of elder abuse, they will overlook it or find alternative explanations for patient injuries. In a study of nursing home staff, Burgess and colleagues[7] found that the staff tended to diminish the gravity of assaults on residents, conveying cynical disbelief and perverse amusement.
Increasing public awareness about the issue of elder abuse increases reports of abuse. States that require public education about elder abuse have higher rates of reporting of abuse.[35] Similarly, states with statutes that mandate the reporting of elder abuse have higher reporting and substantiation rates.[35] Nurses also have a role in educating the public, both about the prevention of elder abuse and about how to report suspected abuse.
Authors and Disclosures
As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.
Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.
Author
Laura A. Stokowski, RN, MS
Staff Nurse, Inova Fairfax Hospital for Children, Falls Church, Virginia; Editor, Medscape Ask the Experts Advanced Practice Nurses
Disclosure: Laura A. Stokowski, RN, MS, has disclosed that she has served as a consultant for Draeger Medical.
Editor
Susan Yox, RN, EdD
Editorial Director, Medscape Nurses
Disclosure: Susan Yox, RN, EdD, has disclosed no relevant financial relationships.
A Betrayal of Trust
Behind closed doors, in the places they call home, many frail, older individuals are harmed by someone they trust. It might be the person who helps them get up in the morning, cooks their meals, or changes their bed linens when they are incontinent. Sadly, this person is not always a paid caregiver who can be dismissed. Often the abuser is a family member, even the elderly person's own spouse or adult child.[1] The nature of the relationship between the elder and his or her abuser is central to understanding mistreatment of the elderly,[2] and stranger violence is excluded from the definition of elder abuse.[3] Conceptually, the core of elder mistreatment is found where age, vulnerability, and a trust relationship intersect.[2]
The tragedy of elder abuse is a growing social problem that crosses all ethnic, racial, economic, and religious lines. That elder abuse has its own specialty (forensic gerontology) and role (geriatric forensic nurse examiner) within the forensic nursing community speaks to the magnitude of this problem.[4] There are many forms of elder abuse -- physical, emotional or psychological, sexual, neglect, abandonment, financial or material exploitation, and self-neglect -- and multiple forms can coexist (Table 1).[5] This article will focus on physical and sexual abuse.
An Epidemic of Mistreatment
Just how many people aged 65 years or older have been abused by someone on whom they depend for care and protection is unknown.[2] Both underrecognized and underreported, elder abuse is a story that can't be told with numbers.[6] We do know that reported incidents of elder abuse are increasing, but formal reports represent only the tip of the iceberg.[7] The National Center on Elder Abuse estimated, in 1996, that only 21% of instances of abuse of a person aged 60 years or older were reported to adult protective service (APS) agencies.[8] A recent systematic review of elder abuse literature concluded that 1 in 4 elders is at risk of abuse,[9] and the Senate Special Committee on Aging believes that as many as 5 million elderly Americans might be mistreated every year.[10]
Healthcare professionals must be vigilant for elder abuse in the clinical setting because an ordeal such as abuse can have far-reaching consequences. The trauma of abuse is magnified in the elderly; it often leads to hospitalization and can significantly shorten the elder person's life.[11] With few strong social support systems and dwindling physical, psychological, and economic reserves, the elderly don't bounce back from the cruelty of abuse.[12] A single incident of maltreatment can trigger a downward spiral leading to loss of independence, serious complicating illness, and even death.[12]
Shame, self-blame, denial, fear of reprisal, unwillingness to accuse family members, or a desire for privacy can all make the older victim reluctant to report abuse to authorities or healthcare providers.[13] Anne Burgess, RN, DNSc, Professor of Psychiatric Mental Health Nursing at Boston College and elder abuse researcher, notes that elders who live at home are fearful that if the abuse is reported, they might be taken out of their homes. "Abuse robs them of their independence," explains Burgess. Cultural characteristics can make some elderly individuals less willing to discuss potential abuse. Some elderly people may not even realize that what they are experiencing is abuse or, if they do, may simply not know how or to whom to report it.[2] For all of these reasons, an astonishing 72% of elders presenting to the emergency department following an incident of abuse do not complain of abuse.[13]
The Circumstances of Abuse
The characteristics of abused elders, both personal and situational, are important in both identification and intervention for elder victims of abuse. Advanced age, absence of significant others, poor health, depression, and cognitive, physical, or functional impairment are the attributes most often associated with victimization in the elderly.[14] Victims are more likely to be female, to suffer from chronic illness, and to live with the caregiver who mistreats them.[15]
Improved understanding of those who abuse and why they abuse is necessary for prevention and early intervention efforts.[16] Perpetrators are more likely to be male, to be emotionally or financially dependent on the elderly person, and to suffer from mental illness, depression, or substance abuse. A poor relationship between the abuser and the abused is often present.[17] Sometimes the abuse is long-term -- essentially spousal abuse that has progressed into old age.
Why does someone intentionally harm an elderly person? Several theories have been proposed. The phenomenon of transgenerational violence posits that children who were abused are more likely to mistreat the parents who abused them.[18] Caregiver stress, from the sometimes overwhelming burden of caring for the elderly, may also be a factor in maltreatment. In generational inversion, the role of parent and child are reversed, and the adult offspring finds it difficult to assume the role of caregiver.[18] When hospitals discharge elderly individuals who require ongoing care into the hands of relatives who don't have the knowledge or ability to provide the necessary care, this could be an abusive situation in the making.[19]
High-risk situations include drug or alcohol addiction in the family, isolation of the elderly person, physical and functional disability, a history of untreated mental illness, a history of family violence, unusual family stress, or excessive dependence of the elderly person on his or her caretaker.[18]
Assessment and Care of the Elderly Patient
Unless you work exclusively in pediatrics, neonatal care, or maternity nursing, geriatrics is part of your practice. Furthermore, this segment of your practice is growing as baby boomers reach retirement age and medical advances extend life expectancy. Few of us are geriatric forensic specialists, and most of us were not taught how to identify and properly document the effects of elder abuse.[20] Still, we must be ready to address the healthcare issues of the aging population, including the needs of the geriatric forensic patient. Hospitals should have a policy for assessing elder patients who might have been abused and for following state legal requirements for reporting and protecting patients from further harm.
Collecting and documenting evidence of abuse is as important in the elderly as it is in children or other patients who have experienced interpersonal violence. Patients with cognitive impairment may be unable to speak for themselves, and, with no witnesses, the full burden of proving abuse rests on the forensic evidence.
Let the Injuries Speak
Dan Sheridan, PhD, RN, FNE-A, SANE-A, FAAN, a forensic nurse examiner and Associate Professor at the Johns Hopkins University School of Nursing, is a strong believer in listening to what injuries are telling him. What appears to be the mechanism of injury? Could assault mechanisms have been involved? Where are the injuries located? Are they on the head, face, and neck, where most injuries from interpersonal violence are found? Are they on the upper extremities, suggesting the possibility of defensive wounds?[21]
When a patient's injuries reveal that they might have been caused by abuse, the nurse must proceed with institutional guidelines for suspected interpersonal violence. As soon as the patient is medically stable, evaluate the wounds for possible trace evidence that might be important in legal proceedings at a later time. Before you wash this trace evidence away or drop it on the floor, preserve and document it.
Mechanism of injury is the exchange of physical forces that results in injury, such as that from a fist, bottle, or bullet.[21] The nurse should look for patterned injuries that display the shape of the object that caused the injury (like a cane or a baseball bat) as these are more likely to be man-made than accidental.[22] Looking at injuries and trace evidence in this way assists in determining if the injuries are consistent, or inconsistent, with how the patient or those accompanying the patient say that the injuries occurred.
Questioning Patients About Abuse
In any setting where elderly patients are encountered, nurses must maintain a high level of suspicion for possible abuse. Screening tools to aid in the identification of elder abuse are available. However, Sheridan has a simple approach for questioning the elderly patient, one that he finds extremely effective in eliciting reports of abuse while simultaneously emotionally supporting the patient.
First, explains Sheridan, it is critical to question the elderly patient alone. Someone among the patient's caregivers or family members could be the abuser, and the patient will not speak freely in their presence. If you ask the patient about abuse in front of the abuser, you might as well not ask at all.
Your first statements are intended to make the patient feel at ease, to convey that there is nothing unusual about the questions you are asking, such as, "Violence is pretty widespread these days -- so widespread that it sometimes spills over into the home. I'm going to ask you a few questions that I ask all my patients."
Next, Sheridan suggests asking: "Where you are living now, are you afraid of anyone?" and then remain quiet to allow the patient to respond. This first question is designed to elicit the emotional aspects of abuse before proceeding to the physical aspects. Sheridan believes that if he demonstrates to the patient that he understands that abuse hurts, emotionally, the patient is more likely to tell him about the physical abuse. Emotional abuse takes longer to heal than physical abuse.
If the answer to the question is yes, then follow up with these 3 statements/questions:
* Thank you for sharing.
* Can you give me an example of how you were afraid?
* When was the last time you were afraid?
The next question is, "Have you been hit, or slapped, or otherwise physically hurt by anyone?" Again, if the patient indicates, "yes" ask the same follow-up questions, along with conveying your sorrow that this happened to the patient. Finally, Sheridan suggests asking the patient if "anyone has forced you to do something sexually that you did not want to do?" After finding out the last time this happened, offer the patient a sexual assault examination.
Throughout questioning, the nurse must remain aware that a patient's reluctance to speak candidly might be related to fear of retribution or institutionalization. It is important to layer questions with emotional support and acknowledgment of the patient's fears about personal safety and other concerns and reassure the patient appropriately.
Forensic Red Flags
When the signs are subtle and the victim is silent about it, elder abuse can easily pass unnoticed.[13] In home care, public health, long-term care, primary care, acute care, emergency care, and outpatient service settings such as dialysis, nurses can uncover elder abuse. Abuse can occur in the home as well as in senior residences and skilled care facilities. Evidence-based markers suggesting abuse or neglect should be part of systematic assessments of elderly patients in all settings of care, regardless of where the patient came from (Table 2).
Repeated visits to the emergency department for complaints of injuries or falls can be an indicator of mistreatment.[19] Verbal reports of harm made by the elderly patient should not be dismissed, even if cognitive impairment is suspected.[2] Allegations should be investigated by an appropriate professional or by law enforcement.
Psychological abuse may be suggested by signs of helplessness, confusion, or disorientation, emotional upset or agitation, unexplained fear, sudden changes in behavior or unusual behaviors (eg, rocking), withdrawal and not responding, or denial and implausible explanations.[19]
Forensic Examination
When preparing to conduct a forensic examination of the elderly victim of abuse, the nurse first obtains consent from the elderly patient or appropriate family member. The exam follows the institution's protocol for conducting an evidentiary exam, preserving evidence, and taking photographs.[23] Some emergency departments find it helpful to maintain a forensics cart, analogous to a crash cart, that contains evidence collection materials. Healthcare professionals who are providing care or collecting evidence must be sensitive to the fact that the elderly individual who was abused by another healthcare worker might fear healthcare professionals.
Physical Abuse of the Elderly
One of the reasons that it is so easy to overlook elder abuse is that there are no hallmarks of abuse in the elderly the way there are in children.[2] Old age often brings medical conditions and physiological attributes that may mimic or mask the markers of elder abuse and neglect.[24] While it can be difficult to ascertain that the elder's signs and symptoms are related to abuse, nurses must remember that they don't have to prove whether or not abuse occurred but only take the appropriate action for suspected abuse.[19]
A common mechanism of abuse in the elderly is the blunt force injury. Blunt force injuries are most often inflicted by punching or slapping with the hands. The major types of blunt force injury seen in interpersonal violence are contusions, fractures, abrasions, lacerations, and internal injuries. Some of these injuries can be accompanied by welts, which are raised, reddened areas caused by striking the individual.
Contusions
Thinner skin, fragile blood vessels, and little subcutaneous fat make the older individual more prone to bruising.[23] Medications, nutritional status, and concurrent medical conditions may also play a role in the occurrence and resolution of bruising in the elderly. Bruises occur more frequently and resolve more slowly in older vs younger persons and can last for months instead of the usual 1 to 2 weeks.
Bruises (also known as contusions) are caused by the rupture of tiny blood vessels under the skin, without breaking the skin.[2] The skin of the eyelids, neck, and scrotum of elders bruises very easily, as do their vulnerable arms and legs.[25] Bruises can also result from squeezing the elderly person. Some bruises retain the shape of knuckles, fists, or fingers used to inflict injury. Parallel bruises, with a lighter, nonbruised area between them, are called tramline bruises, or central clearing, an injury caused by striking the person with a rod-like instrument or stick. Upon impact, the traumatized blood cells in the center are pushed to the sides, resulting in an injury with darker sides and a central area that is lighter in color. Injury from forcing the legs apart during sexual assault might appear as fingertip bruising.
The elderly do fall, and when they fall, they bruise. Clinical differentiation between accidental and inflicted bruises in the geriatric population is difficult. The nurse should examine the elderly patient's entire body for and carefully describe bruises, regardless of possible cause. Objective facts regarding location, size, shape, and color of the bruise, along with the patient's statements about the source of the bruise, should be documented.[24] No attempt should be made to estimate the age of the bruise based on its color[24]; however, if the patient has multiple bruises that appear to be at different stages of resolution, this should be documented.[22]
Accidental bruising occurs in a predictable pattern in older adults. In a study funded by the US Department of Justice, involving 101 elderly individuals, Mosqueda and colleagues[26] found that 90% of accidental bruises occurred on the extremities, and 76% of those were on the dorsal surface of the arm. No accidental bruises occurred on the neck, ears, genitals, buttocks, or soles of the feet. Only 12 of 108 bruises were found on the trunk, all occurring in patients with hypertension, the only medical condition found to correlate with bruising patterns. Individuals on medications known to affect blood clotting were more likely to have multiple bruises, as were individuals with physical disabilities. Although color and appearance of bruises changed over time, the progression was less predictable than previously believed.[26] The ability to recall how the bruise occurred also varied. Subjects were more likely to recall the cause of bruising found on the trunk vs those found on the extremities.
Of note, Sheridan reminds us that nurses sometimes use the word "ecchymosis" erroneously in place of "bruising." Ecchymosis is not a synonym for bruise or contusion. Ecchymosis is extravasation of blood under the skin that can be caused spontaneously by medical conditions, such as thrombocytopenia. Elderly patients frequently have areas of ecchymosis that are not trauma-related. However, the word ecchymosis does have a limited use in the assault-related forensic vernacular. Extravasated blood from a vessel broken by trauma can track through fascial planes, resulting in a discoloration forming at a site remote from the original injury, a gravitational process known as ecchymotic spread. This is how a blow to the scalp can result in a black eye. If, however, the patient was actually struck in the eye, the discoloration in that area is a bruise. The blood from this bruise to the eye area can subsequently gravitate further downward.
Fractures
Low bone density and osteoporosis greatly increase the risk of fractures in the elderly, especially in women. Age, immobility, steroid therapy, cancer, poor nutrition, alcoholism, and hormone deficiencies can all predispose the older individual's bones to fracture.[22] Fractures range from a frank severing of the bone to splintering and compression of the bone.[25] The distal wrist and the hip are the most frequent sites of bone fracture in the elderly. The brittle thoracic rib cage of the elderly individual can lead to rib fractures when force is applied to the chest during an assault.[24]
There are no particular fracture patterns known to be associated with elder abuse.[27] An orthopedic surgeon is the ideal professional to evaluate whether the musculoskeletal injuries correlate with the reported cause of the injuries.[27] Dentists and oral surgeons often see physically abused patients with fractured, subluxed, or avulsed teeth or fractures of the zygomatic arch (the bony structures around the eyes) or the mandible and maxilla (jaw bones).[28]
Abrasions, Lacerations, and Cuts
The elderly victim should be assessed thoroughly for abrasions, lacerations, and cuts, and these injuries should be accurately described using the correct terminology. "Nurses tend to call every wound that is open and bleeding a laceration," explains Sheridan. "But they aren't all the same, and nurses need to learn the differences."
An abrasion is a scraping injury that occurs if the victim is pulled or dragged across a surface that abrades the skin.[24] Abrasions are superficial injuries involving the outer layer of skin. Abrasions are caused by movement of the skin over a rough surface.
Lacerations, sometimes referred to as gashes, are characterized by full-thickness splitting or tearing of the skin, occurring when blunt force is applied. Lacerations often occur over bony prominences and often result in additional trauma to underlying structures.[21] Cuts are very different from lacerations; they are incisions made with sharp objects. Cuts have smooth, clean edges in contrast to the ragged edges of lacerations, evidence that can be seen with a magnifying glass.
Head Injuries
Trauma to the head is more likely to result in a subdural hematoma and carries a greater risk of morbidity and mortality in an elderly individual compared with a younger person.[24] The patient should be evaluated for head injury whether or not there are symptoms.[24] If there is headache, change in mental status, or disturbance in gait, the possibility of head injury must be explored,[24] recognizing that it can be difficult for the healthcare professional, without the observations of those close to the elderly patient, to separate pre-existing neurologic deficiencies from symptoms of a head injury. It is important to assess the scalp for injuries as well. Patchy hair loss suggests violent hair-pulling.[4]
Sexual Assault of the Elderly
Frail elders are vulnerable not only to physical abuse but also to sexual predation.[12] Sexual victimization is most underreported in those over the age of 60 years.[12] As in other forms of abuse and neglect, shame and fear of retaliation prevent many elderly victims from reporting sexual crimes. Furthermore, the stereotype that older adults are not sexual or sexually attractive is a barrier to the detection of sexual abuse in this population.[29] Educating healthcare professionals, including caregivers in long-term care settings, about sexual abuse in the elderly may improve detection.[29]
In a retrospective analysis of the characteristics of 125 elderly sexual assault victims, aged 60 to 98 years, Burgess and colleagues[12] found that one half suffered from a physical disability, 46% from a mental disability, and 33% were diagnosed with dementia. Physical injury was found in 75% of the victims, including a head injury in 38%, abdominal injury in 15%, arm injuries in 30%, vaginal trauma in 45%, and anal trauma in 17%.
What happens after the assault can profoundly affect the subsequent course of justice. Only 37% of the elderly victims described above received forensic examinations. Destruction of forensic evidence (if patient voided, defecated, showered, changed clothes, or brushed her teeth) reduces the likelihood of the offender being charged and found guilty.[12]
In many cases, no anal or pharyngeal specimens were obtained, and vaginal tests were done in only a quarter of the victims. Rape kits were not consistently used and processed, and testing for sexually transmitted diseases was rare. Only 23% of victims were assessed for posttraumatic stress disorder (PTSD). Almost half of these women lived alone at the time of the assault, 38% lived in a nursing home, and 6% in assisted living. Perpetrators of nursing home sexual assaults are rarely prosecuted and convicted of the crime.[12]
Conducting a rape exam on an elderly woman can be difficult if she cannot be placed in the pelvic examination position or has contractures, arthritis, or other conditions prohibiting this position.[24] The patient may be physically resistant to the rape examination and evidence collection.[29] A high-intensity light and small narrow speculum should be used to inspect and photograph any injuries to the exterior genitalia and, if possible, the posterior aspect of the entrance to the vagina and the perineum.[24] Lacerations, abrasions, and bruises may be found in these areas. It is recommended that the exam be conducted by a sexual assault nurse examiner or forensic nurse examiner.
Elderly sexual assault victims are at high risk for posttrauma symptoms such as numbness ("shock"), physiologic upset, startle reflex, and anger.[30] Posttraumatic sequelae are often overlooked by healthcare professionals or ruled out as being normal variants of the aging
process,[30] yet these are serious issues that affect the elder's quality of life. Elderly patients who have been sexually assaulted should have psychotherapeutic intervention in the aftermath of the assault.
Documentation
Data entered into the medical record can be used as evidence if elder abuse is prosecuted or there is a civil lawsuit. Documentation may also be used in guardianship hearings.[31] The nurse should document findings of physical examination, forensic evidence collection, and any statements made by the patient or those accompanying the patient as objectively and accurately as possible. The chain of custody must be maintained on any physical evidence collected for forensic
purposes.[31]
Nonforensic nurses often make documentation errors that can even result in their documentation and testimony being excluded from legal proceedings at a later time. One of these errors, according to Daniel Sheridan, is using the word victim when charting. "The word victim should never appear in the medical record," explains Sheridan. "We care for patients, not victims. Using the word victim suggests that the nurse has already decided that the patient was abused, and he or she is biased in favor of abuse."
Another legal term that should not appear in nurses' documentation is "alleged." "If it would be inappropriate to chart alleged chest pain, it is just as inappropriate to chart alleged elder abuse," Sheridan said, adding, "instead of charting alleged, replace it with reported or suspected." To maintain objectivity, the nurse should document the statements made by patients, family members, or caregivers. It is wrong, however, to sanitize or medicalize the patient's words. Sheridan explains that nurses should try to write down patient statements verbatim, in quotes, without changing the patient's words, including slang terms for body parts, to those that a medical professional might use.
Next Steps
Although forensic evidence collection is important, nurses must also initiate the processes of safety, services, and support for elderly victims.[5] Social services, counseling, and legal assistance should be initiated.[4]
Safety for Abused Elders
Elderly victims of abuse are usually incapable of protecting themselves. It is imperative for healthcare professionals who suspect abuse to intervene and ensure the safety of the elderly patient. It is obviously a difficult situation when the abuser is the family member, caregiver, or friend who accompanied the patient to the healthcare facility. The nurse must make the best assessment possible of the potential danger in the patient's living situation.
Plans must be rapidly formulated if the injured elder is going to be released from the emergency department, acute care, or urgent care facility, to prevent sending the victim back to an unsafe environment.[32] Following state and institutional elder abuse reporting guidelines is the first
step.[32] Nurses are often reluctant to fulfill their responsibility to report suspected elder abuse, preferring to leave it to the social worker or some other individual to do the reporting. However, as Daniel Sheridan points out, the nurse is the one closest to the information, who has assessed the patient and talked to the patient and family, and should be the one making the report.
States have made it very easy to report suspected abuse of older adults, and most require healthcare professionals to do so. For example, Virginia law designates, among others, anyone who holds a license granted by a health regulatory board, such as the Board of Nursing, as a mandated reporter of elder abuse. A 24-hour toll-free elder abuse hotline is available for immediate reporting. Failure to report suspected abuse within 24 hours in Virginia can result in civil fines.[33] Texas law requires any person who believes that an adult over the age of 65 years or with disabilities is being abused to report the circumstances to the Department of Family and Protective Services, and failure to do so is a Class B misdemeanor. Suspected abuse can be reported confidentially via telephone hotline or the state's secure abuse Web site.[34] Some state attorney general offices and district attorney offices have established special elder abuse investigation and prosecution units.
A complete list of states' links to government agencies, state laws, state-specific data and statistics, and resources for elder abuse is available at the National Center on Elder Abuse (NCEA) Web site.
Services for Abused Elders
APS agencies aim to ensure the safety of the elderly person at risk of being mistreated, and who is unable to protect him or herself.[1] Most jurisdictions specify that reports be made directly to APS, but others require the report to be submitted first to law enforcement.[2] Reports of abuse, exploitation, or neglect are investigated by APS agencies to determine the need for casework services such as monitoring and evaluation. These agencies arrange for medical care, social services, economic or legal aid (including restraining orders), safe housing or shelters, and other protective and supportive services. Adult protection agencies also liaise with law enforcement as indicated. APS caseworkers are often the first responders to reports of elderly abuse, neglect, or exploitation.[1]
APS can offer services to protect the elderly victim, but these services are voluntary; the elderly individual can choose to accept or decline them. APS can arrange for emergency housing, cleaning services and home repairs, medical services and medications, referral to other healthcare providers, and assistance with applications for healthcare benefits; addressing personal needs for food and caretaker services. APS can also coordinate care and support on a short-term basis, provide a client advocate and implement legal interventions, such as restraint orders, guardianship, involuntary mental health commitments, and emergency removals.
Attention to elder abuse lags significantly behind that for child or spousal abuse.[4] Oddly, society seems more tolerant of abuse in the elderly than in children. Nurses rarely hesitate to contact child protective services in cases of suspected child abuse. We might, however, neglect to pick up the phone on behalf of the elderly patient with injuries suggesting abuse. Whether this reflects ageism, lack of time, lack of clarity as to what constitutes abuse, ignorance about reporting protocols, or respecting the elderly patient's wishes isn't yet known.[4]
Support for Abused Elders
Follow-up care is necessary to ensure the well-being of the victim of abuse.[32] APS is one source of ongoing support services, but other community-based services such as adult day-care, respite care, and caregiver support services should also be used. A home care or visiting nurse is vital for elderly victims released to the environment where mistreatment occurred. Sometimes an older adult will decline services of any kind and insist on returning to the setting of mistreatment. Unless there is true cognitive impairment, healthcare professionals cannot force the elderly person to go to a shelter or move to a protected living situation. This can be an ethical dilemma for nurses taking care of the elderly patient. Written materials, with 24-hour emergency numbers, should accompany the elderly individual who declines services.
A geropsychiatric consultation is important for elderly victims of assault. In those who are cognitively impaired or have documented dementia, the geropsychiatric nurse can conduct a detailed assessment and determine if impairments exist that preclude self-determination.[32] The geropsychiatric nurse can evaluate the elderly patient for PTSD or rape trauma related to sexual assault. Posttraumatic symptoms should not be overlooked or written off as medical or psychological signs of aging.[30]
Prevention of Elder Abuse
Nurses and other caregivers must be trained to identify the signs of elder abuse, even when the patient does not volunteer the information. If healthcare personnel are skeptical about the reality of elder abuse, they will overlook it or find alternative explanations for patient injuries. In a study of nursing home staff, Burgess and colleagues[7] found that the staff tended to diminish the gravity of assaults on residents, conveying cynical disbelief and perverse amusement.
Increasing public awareness about the issue of elder abuse increases reports of abuse. States that require public education about elder abuse have higher rates of reporting of abuse.[35] Similarly, states with statutes that mandate the reporting of elder abuse have higher reporting and substantiation rates.[35] Nurses also have a role in educating the public, both about the prevention of elder abuse and about how to report suspected abuse.
Authors and Disclosures
As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.
Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.
Author
Laura A. Stokowski, RN, MS
Staff Nurse, Inova Fairfax Hospital for Children, Falls Church, Virginia; Editor, Medscape Ask the Experts Advanced Practice Nurses
Disclosure: Laura A. Stokowski, RN, MS, has disclosed that she has served as a consultant for Draeger Medical.
Editor
Susan Yox, RN, EdD
Editorial Director, Medscape Nurses
Disclosure: Susan Yox, RN, EdD, has disclosed no relevant financial relationships.
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